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BMJ 1996; 312 doi: (Published 20 January 1996) Cite this as: BMJ 1996;312:0

“Miraculous” developments from health services research

Imagine that we were publishing today a paper that described a drug or operation that caused a 16% reduction in the risk of dying in women with breast cancer. There would be worldwide interest. If it was a drug that caused the improvement then the manufacturer's share price would rise; if it was an operation then the surgeon who developed it would become a celebrity. In fact, we publish a paper that describes such a reduction in mortality from being cared for by surgeons with a specialist interest in breast cancer rather than by general surgeons (p 145). The reason for the improvement is not clear, and it could possibly be that the women who went to the specialist surgeons were at lower risk. But this is unlikely. How then to define a specialist? Charles Gillis and David Hole, the authors of the study, define specialists as those who set up dedicated breast clinics, have a defined relationship with pathologists and oncologists, organise clinical trials, and keep separate records of all patients seen in their clinics. They argue that all patients with breast cancer should be cared for by specialists, and they wonder if the same results might be seen with other conditions.

Now imagine a paper describing a drug that could reduce the need for emergency admission to hospital by 10%. The British government would be especially pleased because it is coming under enormous public and professional pressure to respond to increasing emergency admissions and pressure on beds and acute hospitals (p 139). There is no such drug, but a paper from Bristol shows that three different groups of doctors (general practitioners and hospital consultants) agreed that 5-5% to 14% of acute admissions could be managed in other ways for instance, being given urgent outpatient appointments or being admitted to beds managed by general practitioners (p 162). This paper both illustrates how dramatic improvements may come from researching the organisation and delivery of care, and perhaps we can expect as much from such unglamorous health services research as we can from molecular biology.

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